A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma Incident. Which of the following interventions should the nurse take first?

Reassure staff members that the debriefing is confidential.

Have staff members discuss their involvement in the event.

Ask staff members to describe their most traumatic memories of the event.

Provide stress-management exercises to the staff members.

Answer and Explanation

The Correct Answer is A

A. "Reassure staff members that the debriefing is confidential."
This is an appropriate first step. Ensuring confidentiality creates a safe environment where individuals feel comfortable sharing their experiences and emotions.

B. "Have staff members discuss their involvement in the event."
This can be a part of the debriefing process, but it might not be the first step. Generally, individuals are given the option to share their experiences, but they should not be forced to do so. Some might not be ready to talk about their involvement immediately.

C. "Ask staff members to describe their most traumatic memories of the event."
This might be too intrusive as a first step. It's important to approach discussions about specific traumatic memories with caution and only when individuals are comfortable sharing.

D. "Provide stress-management exercises to the staff members."
This could be a helpful step after ensuring confidentiality and allowing individuals the opportunity to express their feelings. Stress-management exercises can provide valuable coping strategies.

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Correct Answer is B

Explanation

A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.

B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.

C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.

D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.

A. Determine the client's degree of physical dependence. B. Discuss the treatment plan with the client. C. Document the client's alcohol use in the medical record. D. Initiate a referral for treatment for alcohol use disorder.

Correct Answer is C

Explanation

A. Determine the client's degree of physical dependence:
This action is important but usually comes after the initial assessment and documentation. Assessing the degree of physical dependence involves evaluating the client's withdrawal symptoms, tolerance, and other physical health parameters. It helps in planning the appropriate level of care, such as detoxification if needed.

B. Discuss the treatment plan with the client:
While discussing the treatment plan is crucial, it's typically done after gathering essential information about the client's alcohol use, medical history, and current condition. The treatment plan is tailored based on the gathered data, which includes documenting the client's alcohol use.

C. Document the client's alcohol use in the medical record:
This is the first step because it provides a formal record of the client's alcohol use history, including patterns and any associated complications. Documenting this information helps in comprehensive care planning and ensures that all healthcare providers involved in the client's treatment have accurate and up-to-date information.

D. Initiate a referral for treatment for alcohol use disorder:
Referrals are essential, but they usually follow the initial assessment and documentation. The referral process involves connecting the client with appropriate resources, such as addiction specialists, counselors, or support groups, based on the documented information and the client's needs.

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A nurse is leading a critical incident stress debriefing with a group of staff members following a mass trauma Incident. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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